Cycle 1
Health 2025-02-06 · Fire 2025-02-06
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Asheville, NC
Givens Health Center
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
600 Barrett Lane, Asheville, NC
(828) 771-2900
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
59
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.98
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.98
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.74
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.97
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.14
CMS adjusted RN staffing hours
Adjusted total hours
5.50
CMS adjusted total nurse staffing hours
Case-mix index
1.18
Higher values indicate more complex resident acuity
RN turnover
38%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,004
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.36
Composite VBP score used to determine payment impact.
Payment multiplier
1.0069
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.11
Baseline 16.44% · Performance 19.99% · Measure score 3.11 · Achievement 3.11 · Improvement 0
Healthcare-associated infections
4.35
Baseline 5.45% · Performance 6.54% · Measure score 4.35 · Achievement 4.35 · Improvement 0
Total nurse turnover
6.28
Baseline 43.33% · Performance 38.03% · Measure score 6.28 · Achievement 6.28 · Improvement 2.37
Adjusted total nurse staffing
7.21
Baseline 3.89 hours · Performance 5.13 hours · Measure score 7.21 · Achievement 7.21 · Improvement 6.06
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.68% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 168 · Observed rate 6.55% · Lower 95% interval 6.94% |
| Discharge to community | 59.59% |
50.57%
9 pts better
|
Better than the National Rate · Eligible stays 146 · Observed rate 62.33% · Lower 95% interval 51.64% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 75.93% |
95.27%
19.3 pts worse
|
Numerator 82 · Denominator 108 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 108 |
| Discharge self-care score | 65.69% |
53.69%
12 pts better
|
Numerator 67 · Denominator 102 |
| Discharge mobility score | 67.65% |
50.94%
16.7 pts better
|
Numerator 69 · Denominator 102 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 108 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.53% |
7.12%
0.6 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 3.92% · Lower 95% interval 3.65% |
| Staff COVID-19 vaccination coverage | 1.53% |
8.2%
6.7 pts worse
|
Numerator 2 · Denominator 131 |
| Staff flu vaccination coverage | 30.99% |
42%
11 pts worse
|
Numerator 44 · Denominator 142 |
| Discharge function score | 75.49% |
56.45%
19 pts better
|
Numerator 77 · Denominator 102 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.3% |
96.28%
1 pts better
|
Numerator 72 · Denominator 74 |
| Resident COVID-19 vaccinations up to date | 26.56% |
25.2%
1.4 pts better
|
Numerator 17 · Denominator 64 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 2.0 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
91.5%
6.9 pts better
|
93.4%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.8% · Q4 96.0% · 4Q avg 98.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.9% |
94.1%
5.2 pts worse
|
95.5%
6.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 14.2% |
3.6%
10.6 pts worse
|
3.3%
10.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 12.5% · Q3 17.8% · Q4 12.0% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.4% |
4.8%
2.4 pts better
|
11.4%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 8.3% · 4Q avg 2.4% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
7.2%
0.8 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.3% · Q3 3.2% · Q4 8.6% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.1% |
21.6%
15.5 pts better
|
19.6%
13.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.1% · Q3 8.8% · Q4 8.1% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
15.0%
6.1 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 21.9% · Q3 25.9% · Q4 21.2% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 26.8% |
21.5%
5.3 pts worse
|
16.3%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.9% · 4Q avg 26.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
16.8%
8.2 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.6% · Q2 50.0% · Q3 12.9% · Q4 16.1% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.8% |
0.9%
1.9 pts worse
|
1.0%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 4.0% · Q4 3.1% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.2% |
2.6%
0.4 pts better
|
1.7%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 2.2% · Q3 0.0% · Q4 4.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.5% |
21.2%
7.3 pts worse
|
19.8%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.6% · Q2 51.3% · Q3 19.0% · Q4 10.1% · 4Q avg 28.5% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
6.0%
About the same
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.8% · Q3 4.9% · Q4 5.1% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.7% |
79.9%
16.8 pts better
|
81.7%
15 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 97.6% · Q3 99.0% · Q4 97.0% · 4Q avg 96.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
13.2%
4.8 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 7.1% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.4% |
78.1%
3.7 pts worse
|
79.7%
5.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.3% |
22.9%
0.4 pts worse
|
23.9%
0.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 18.3% · Expected 18.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-21 · Fire 2023-12-21
13 health deficiencies
Top issue: Resident Assessment and Care Planning (7 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-08-26 · Fire 2022-08-26
2 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-02-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-20
D · Potential for more than minimal harm
2023-12-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-10
D · Potential for more than minimal harm
2023-12-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-10
D · Potential for more than minimal harm
2022-08-26
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2022-10-27
C · Minimal harm
2022-08-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-06
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-06
D · Potential for more than minimal harm
2023-12-21
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-23
D · Potential for more than minimal harm
2023-12-21
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-01-23
B · Minimal harm
2023-12-21
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-01-23
B · Minimal harm
2023-12-21
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2024-01-23
F · Potential for more than minimal harm
2022-08-26
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-09-14
D · Potential for more than minimal harm
2022-08-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-09-14
Penalties and ownership
What sits behind the stars
Ownership
Givens Estates, Inc.
5% Or Greater Direct Ownership Interest · Organization
Cowan, John
Corporate Director · Individual
Partin, Kenneth
Corporate Officer · Individual
Partin, Kenneth
W-2 Managing Employee · Individual
Shepherd, Robert
Corporate Director · Individual
Smith, Patricia
Corporate Officer · Individual
Squires, Allen
Corporate Officer · Individual
Sudderth, Robin
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Deerfield Episcopal Retirement
Asheville, NC
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Biltmore Haven Nursing and Rehabilitation
Arden, NC
1-star overall rating with 1-star inspections with Special Focus status with $172,134 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Laurels Of Greentree Ridge
Asheville, NC
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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